One of the key challenges we face is the fragility of some of our services. This is particularly the case in maintaining so many medical rotas, and this means that we cannot continue to run all acute services at both Glangwili and Withybush hospitals.
We have had to respond to changing needs and expectation on our doctors during the last 20 years and our doctor on-call rotas have had to change. To improve training opportunities and performance, doctors both in training and at consultant level are expected to be on-call less frequently and work fewer hours than in the past. At the same time, standards and expectations of care have increased, with timely access to senior decision-makers required to assess patients in our hospitals throughout the week and weekend. Other health organisations in Wales and across the UK can offer less frequent more attractive on-call rotas.
This has all resulted in a challenge for the health board in providing enough doctors in all our hospitals to continue to provide services. This means we rely too much on temporary staff to deliver services. This is not the safest way to provide care. It is also expensive and whilst money is not an overriding factor in why we need to change, it plays a significant part in us being able to provide better healthcare and to better support services in community and primary care.
Another benefit of aligning some of our specialist staff, is allowing them the opportunity to see sufficient patients to maintain and build their expertise in certain areas and to work in networks. This will bring opportunities to provide a wider range of services within Hywel Dda than is currently possible. By providing and supporting specialisms we can provide safer services and improve outcomes for patients.
Of course, it’s not only medical staff where we have challenges to recruit, this is also true in nursing and other professions. We routinely can have as many as 950 whole time equivalent vacancies (which is about 10% of our staff). This makes some of our services very fragile, difficult to sustain and not the highest quality that we want to provide.
Bronglais, Glangwili, Prince Philip and Withybush hospitals will continue to provide a range of important services for the local population, alongside the new Urgent and Planned Care Hospital in the south of our area. This means that people’s care would predominantly still be provided locally.
This would not address the problems we have with maintaining our medical rota, nor some of the problems we have with the buildings, particularly at Glangwili Hospital.
Whilst we have upgraded our current hospitals to keep them safe and functional, they do not address the fundamental service re-design necessary for us to meet modern healthcare standards in the future. For example, our theatres are too small, we do not have enough single rooms, nor facilities that support rehabilitation, such as in wards.
In our PBC the “do minimum” option estimates we could spend up to £655m on our buildings and still not be able to provide the standards required to deliver modern healthcare or the flexibility needed for the future.
For detail on our challenges with medical rotas see question Why do we need a new hospital, why can’t you upgrade the ones you have?
In our option development stage (prior to formal consultation in 2018), options to provide emergency and urgent care for the south of Hywel Dda either from Withybush Hospital, in Haverfordwest, or Glangwili Hospital, in Carmarthen, were considered.
They were eliminated due to the distance of travel for this type of care that would be required for people in the neighbouring county (i.e., travel too great for people in Carmarthenshire when sited at Withybush and travel too great for people in Pembrokeshire when sited in Glangwili).
We know that people from coastal Pembrokeshire must travel to Glangwili Hospital for a range of urgent and emergency services now which has been a driver to move the main emergency unit further west. However, if the main emergency unit is too far west then it would affect access for the population in north Carmarthenshire and some services such as obstetrics and paediatrics (and therefore other services) would not have enough activity to be sustainable and may be lost completely.
Our proposals for the new hospital, were mapped to ensure we provide an emergency service that is as close as possible to being within an hour of most populations in our area. This is how we arrived at the zone for the new hospital, somewhere between St Clears and Narberth. Whilst no land has been purchased for the new hospital site, a land selection process has started.
A new hospital alone will not be enough to address our challenges and deliver the vision we aspire to for our communities. That is why our PBC includes a huge focus on improvements in the heart of our communities, and support for our strategy to shift focus to prevention, early intervention, and care as close to home as possible.
If supported, a new hospital will however provide many opportunities for us to improve care for our population. Glangwili and Withbush Hospitals are some of the oldest in Wales and don’t meet the standards for modern health care buildings. This impacts on patient experience and the quality of services we can provide. Equally the duplication of services across sites means many are fragile and don’t have the necessary scale to provide care in the way we would want (7-day cover for example).
We also believe there are additional services we could offer from a new hospital, within the boundaries of Hywel Dda, which we are not able to now. We are keen to explore, in conjunction with Swansea Bay University Health Board, options for providing some tertiary services, for example radiotherapy, neurology services, and cardiac catheterisation services. Each of these services is being reviewed regionally through the ARCH partnership.
The experience we have seen in other places where there has been a new hospital is that staff want to go and work there as they have the latest facilities and technologies. It would also allow us to offer more attractive rotas to medical staff and trainees. We propose to have a health education, academic and research and innovation facilities on the site, including an Institute for Life Sciences. It is not just about doctors; we have had discussions and want to work closely with health sciences to train and attract nurses and therapists too.
By having a stable workforce, we will have more senior, specialists available at the front door so patients have quick access to them, as well as all the support services needed. We will also reduce our reliance on temporary staff, which is costly and can result in less safe service provision.
Finally, by separating planned and emergency care, as we intend to at the new hospital, we will avoid the risk of emergency activity negatively impacting on planned care, through cancelled operations.
We are keen to explore, in conjunction with Swansea Bay University Health Board, options for providing services that are tertiary, for example radiotherapy, neurology services, and cardiac catheterisation services. Each of these services is being reviewed regionally through the ARCH partnership.
The Urgent and Planned Care Hospital would provide specialist mental health and learning disability services 24/7. This would include beds for adults, older adults, children, and adolescents, learning disabilities, psychiatric intensive care, male low secure beds, and assessment and day facilities, as well as dedicated and appropriate section 136 suites.
Facilities should be provided in a dedicated unit, ideally with connectivity to the main hospital site. This unit will be an integral part of the overall mental health service offering, specialist input in addition to that provided within community facilities.
Bronglais Hospital would continue to have older adult mental health beds as it does now.
NB for questions on site selection and purchase of land, please see chapter above on process.
Any pathway we put in place, including safe transfer to an appropriate hospital, will need to be safe for our population. Our programme of transformation has been clinically led, specifically to ensure what we propose is safe for our patients.
The term 'golden hour' is not a simple 60 minutes - current maximum travel times differ depending on your condition. Emergency response starts at the point of the call to the ambulance service’s clinical contact centre and the arrival of the emergency crew. Paramedics are highly trained and can often provide the immediate care required to allow the extra journey time for patients to be treated at the most appropriate hospital. Some emergencies would also see the response of clinicians, including consultants, at the scene from the Emergency Medical Retrieval and Transfer Service (EMRTS Cymru).
We continue to see advances in provision from emergency services in Wales such as the extension of the Wales Air Ambulance to a 24/7 service since July 2020.
By making improvements to our staffing challenges and safety of our specialist services, through the new Urgent and Planned Care Hospital, we will also have more senior, specialist doctors available at the front door so you have quick access to them, and all the support services needed for your care.
By separating planned and emergency care, as we intend to at the new hospital, we will also avoid the risk of emergency activity negatively impacting on planned care, through cancelled operations.
We have worked closely with the Welsh Ambulances Service NHS Trust since we embarking on our programme of transformation. They have modelled the impact of changes using sophisticated software to understand whether it has sufficient ambulances that can respond in a way in which does not put more pressure on the system. We will continue to work together to ensure their staff are able to transport patients safely to a hospital in an emergency.
A fundamental part of our strategy is to shift more focus onto community based, person-centred, preventative care to provide early help to keep people well and reduce worsening of ill-health. This will reduce emergency admissions.
We have more work to do to review each acute pathway for hospital care, including stroke, cardiac events, and major trauma. As we consider individual patient pathways, we will continue to work closely with Welsh Ambulance Services NHS Trust (WAST) and EMRTS Cymru, as well as neighbouring health boards, to ensure equity of access to emergency care for the population of Hywel Dda.
The ambulance service is also working with commissioners and NHS partners to develop a model for transferring patients between hospitals, ensuring that those who are in the greatest need of timely care can be transported to the right place first time and taking pressure off conveying resources.
The Welsh Ambulance Services NHS Trust has embarked on a national roster review to ensure that resources pan-Wales are best placed to meet growing demand on its service. While the roster review is underway, the Trust cannot yet say what precise level of emergency cover will emerge, but they do expect the overall level of cover in Hywel Dda to increase. The Trust is committed to keeping communities up-to-date and informed of progress.
We will continue to develop our plans alongside our colleagues in the Welsh Ambulance Service NHS Trust.
Our plans do not involve closing any of our current emergency and urgent care services in advance of any new alternatives, such as a new hospital, being agreed and put in place.
At the same time, we are facing unprecedented pressures, including our response to the COVID-19 pandemic and the impact this has on our staffing and how we can deliver care safety. Our clinicians and managers will continue to make operational decisions and react to changing circumstances every day to ensure we can safely treat our patients. In this context absolute guarantees are very hard to make but it is our intention to keep the existing A&Es open ahead of the new hospital.
These sites will operate as local community hospitals, with therapy and nurse-led beds, focusing on rehabilitation and less acute needs.
They will allow us to provide same day emergency care for ambulatory (walk-in) conditions, with GP-led urgent care centres/minor injury units.
They will have step-up and step-down beds. These provide an alternative to a hospital stay for people who need more care and treatment than can be provided to them at home, or to enable people to be discharged from hospital following an acute illness or operation if they need a period of rehabilitation.
They will have facilities for some day case procedures and be able to undertake tests like x-ray, ultrasound, and mammography.
We need to undertake further work with our clinical and other staff, partners, and the public to engage on the detail of our service pathways. However, typically, a GP-led urgent care centre would provide care for injuries and illnesses, such as:
We need to undertake further work with our clinical and other staff, partners, and the public to engage on the detail of our service pathways.
The Programme Business Case provides a prospectus of options, which if endorsed by the Welsh Government, will require further development in the next business stage.
At this stage, we have included an option for Glangwili and Withybush hospitals for ‘minimum’ transformation. That would assume we would keep seven wards (24 inpatient beds each), two day-theatres and an endoscopy suite at Glangwili, and four wards (24 inpatient beds each), two day-theatres and an endoscopy suite at Withybush hospitals
The ‘likely’ scenario, and ‘maximum efficiency’ scenarios would both result in us keeping three wards (24 inpatient beds each) at Glangwili Hospital and two wards (24 inpatient beds each) at Withybush Hospital with all day surgery activity and the clinical support services re-located to the new Urgent and Planned Care Hospital.
To properly appraise all options, as required by Welsh Government business case process, the next stage would look in more detail at how we re-purpose Glangwili and Withybush hospitals. This would include options to use the current buildings, but also potential to re-build.
If endorsed by the Welsh Government, the programme will include refurbishment of Prince Philip Hospital by winter 2032.
The hospital will remain as a local general hospital, supporting acute medical admissions and acting as a stabilisation and transfer hub for certain specialised conditions, as it does now. It will continue to have:
If endorsed by the Welsh Government, the programme will include refurbishment of Bronglais Hospital by spring 2031.
The hospital will remain as a district general hospital and build its reputation as an excellent rural provider of acute and planned care. It will continue to provide the current range of urgent, emergency, and planned care services with more specialist cases transferred to the main Urgent and Planned Care Hospital (as well as other regional sites for critical care), as happens now.
Given the site constraints there is no new-build option for the hospital.
It will continue to have:
Bronglais Hospital will have at least the same range of clinical services as presently, and the University Health Board will be looking to expand services where possible to ensure long-term clinical sustainability, supporting the Bronglais Strategy.
We recognise that Bronglais has a unique position in Wales, which means that a significant part of its role is providing care to residents from other Health Board areas.
We want each of our seven localities to have one or more health and well-being centres or community hospitals – together we refer to these as community hubs. They may all be slightly different, in line with the needs of their communities, but they will bring people and services together in one place and provide virtual links between the population and the wider community network of support.
Multidisciplinary teams of different staff and support services will wrap around individuals and families.
In addition to providing access to diagnostics (tests and scans etc) and consultations, hubs will also have community beds to prevent individuals from needing to go to hospital, and to support timely discharge from hospital. These may be in people’s own homes, in local nursing and residential homes, or in some of the health and well-being centres.
The range of services could include, some or all of the following:
Services offered in health and well-being centres will also be provided from current community facilities, which have a variety of names, and in Glanwgili and Withybush hospitals in their roles as community hospitals.
We plan to offer community facilities with beds in the following locations:
We plan to offer community facilities without beds in the following locations:
A separate Programme Business Case focusing on mental health services is being progressed and mental health provision within community-based facilities is subject to further discussion.
Community service provision will however include the development of Community Mental Health Centres so people can access support and treatment in a homely environment close to their home.
Currently there are mental health facilities on the existing hospital sites in Bronglais Hospital, Aberystwyth, Glangwili Hospital, Carmarthen, Prince Philip Hospital, Llanelli, and Withybush Hospital, Haverfordwest. Further development of the model will determine whether the new services should be within those sites or elsewhere within the local community.
Community health and well-being centres would also offer mental health advice and support.
Some community facilities are already delivered: Cardigan integrated Care Centre and Aberaeron Integrated Care Centre.
Some are progressing outside of this programme business case through other funding routes: Pentre Arwel, Llanelli, with completion of phase one planned for January 2024; Clych Caron, Tregaron, which is currently at full business case stage; and Carmarthen Hwb, currently working towards award of contract with completion planned for early 2024.
The Cross Hands Health and Wellbeing Centre is currently at outline business case stage with opening anticipated for early 2025.
All other community schemes are currently at scoping stage and need more detailed prioritisation, and phasing.
The PBC recognises the need to create a digital infrastructure that will enable the health board to connect with patients and service users in all settings, creating a health system ‘without walls.’ This would include innovations, such as wearables, more advanced electronic health records, and greater use of technology to simplify processes including admission and discharge.
We have signed a Digital Inclusion Charter and as part of this commitment we will support a comprehensive programme of work around digital inclusivity. The programme will help patients, carers, and staff, so they can navigate the health and wellbeing risks of the internet and social media.
It will also help people with low digital skills to understand how their health data is used and explain and encourage the benefits digital can offer for their health and wellbeing. Digital access and skills can affect our health (a social determinant of health), so in supporting digital inclusivity we will tackle inequalities.
We have committed to co-design digital health solutions with the public, placing patients at the heart of the design. We will develop “digital health hubs” to reach poorly served groups, reduce digital inequalities, and build trust in the technologies that we think can help people and the health service. At the forefront of our future design of buildings, we will be exploring and using the benefits of digital health and wellbeing, ensuring that patients, and carers, are not excluded whilst testing devices and assistive technologies.
It is through this transformation that the health board believes it can support the delivery of the NHS Wales decarbonisation strategy. At its heart our strategy is to provide services closer to home and rebalance our system to one focused on prevention and early intervention. This, we believe, is not only better for patients but will also impact less on the environment.
Our current buildings, particularly Glangwili, are amongst the oldest and least efficient in Wales. The plans we have for new and improved facilities offer the opportunity to radically reduce the carbon footprint and environmental impacts of our estate. The design of new buildings will be what is referred to as ‘smart’ or ‘intelligent.’ By this, we mean they can support provision of technology and collection of data, which supports and improves the operational running and security of the buildings. Smart buildings create environments that can interact with the people within them, learn from them, and adapt to their changing needs. Information management systems in buildings, can increase comfort, efficiency, resilience, and safety. They can integrate lighting, power, security, fire safety, heating, ventilation, and air conditioning.
We want our communities to be involved in designing our buildings, and when the new Urgent and Planned Care Hospital is built and the rest of our estate improved, we want our facilities to feel like they are public assets, open to the community; and connected to the local natural environment. Indeed, we see an opportunity, through adopting ‘biophilic’ design principles for the new hospital and other sites, to provide a calmer and more pleasant environment for patients and staff, which will benefit care reducing recovery times and medication use.
As part of the PBC the importance of transport is recognised, and the Health Board has an ambition to support the transition to low carbon and active travel. We are aware that many households in Hywel Dda do not benefit from access to a car and we are working with Transport for Wales to maximise the opportunity for patients, visitors, and staff to utilise public transport to access our services.